Provider Demographics
NPI:1689941932
Name:SU SALUD CLINIC PSC
Entity Type:Organization
Organization Name:SU SALUD CLINIC PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY PRACTICE/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:AUGUSTO
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-444-5695
Mailing Address - Street 1:4101 DIPLOMAT PLAZA CTR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46806-4531
Mailing Address - Country:US
Mailing Address - Phone:260-444-5695
Mailing Address - Fax:260-444-5665
Practice Address - Street 1:4101 DIPLOMAT PLAZA CTR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46806-4531
Practice Address - Country:US
Practice Address - Phone:260-444-5695
Practice Address - Fax:260-444-5665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-30
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01056928A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty